Exam Questions - Med Surg

7/29/2019 Exam Questions - Med Surg

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MEDICAL-SURGICAL NURSINGPart 1

1. After a cerebrovascular accident, a 75 yr oldclient is admitted to the health care facility. The

client has left-sided weakness and an absentgag reflex. Hes incontinent and has a tarrystool. His blood pressure is 90/50 mm Hg, andhis hemoglobin is 10 g/dl. Which of the followingis a priority for this client?a. checking stools for occult bloodb. performing range-of-motion exercises to theleft sidec. keeping skin clean and dryd. elevating the head of the bed to 30 degrees

ANS: DBecause the clients gag reflex is absent,

elevating the head of the bed to 30 degreeshelps minimize the clients risk of aspiration.Checking the stools, performing ROM exercises,and keeping the skin clean and dry areimportant, but preventing aspiration throughpositioning is the priority.

2. The nurse is caring for a client with acolostomy. The client tells the nurse that hemakes small pin holes in the drainage bag tohelp relieve gas. The nurse should teach himthat this action:a. destroys the odor-proof seal

b. wont affect the colostomy systemc. is appropriate for relieving the gas in acolostomy systemd. destroys the moisture barrier seal

ANS: AAny hole, no matter how small, will destroy theodor-proof seal of a drainage bag. Removing thebag or unclamping it is the only appropriatemethod for relieving gas.

3. When assessing the client with celiacdisease, the nurse can expect to find which ofthe following?a. steatorrheab. jaundiced scleraec. clay-colored stoolsd. widened pulse pressure

ANS: Abecause celiac disease destroys the absorbingsurface of the intestine, fat isnt absorbed but ispassed in the stool. Steatorrhea is bulky, fattystools that have a foul odor. Jaundiced scleraeresult from elevated bilirubin levels. Clay-coloredstools are seen with biliary disease when bileflow is blocked. Celiac disease doesnt cause a

widened pulse pressure.

4. A client is hospitalized with a diagnosis ofchronic glomerulonephritis. The client mentions

that she likes salty foods. The nurse should warnher to avoid foods containing sodium

because:a. reducing sodium promotes urea nitrogenexcretionb. reducing sodium improves her glomerularfiltration ratec. reducing sodium increases potassiumabsorptiond. reducing sodium decreases edema

ANS: DReducing sodium intake reduces fluid retention.Fluid retention increases blood volume, whichchanges blood vessel permeability and allowsplasma to move into interstitial tissue, causingedema. Urea nitrogen excretion can beincreased only by improved renal function.Sodium intake doesnt affect the glomerularfiltration rate. Potassium absorption is improvedonly by increasing the glomerular filtration rate; itisnt affected by sodium intake.

5. The nurse is caring for a client with a cerebralinjury that impaired his speech and hearing.Most likely, the client has experienced damageto the:a. frontal lobeb. parietal lobec. occipital lobed. temporal lobe

AN:S DThe portion of the cerebrum that controls speechand hearing is the temporal lobe. Injury to the

frontal lobe causes personality changes,difficulty speaking, and disturbance in memory,reasoning, and concentration. Injury to theparietal lobe causes sensory alterations andproblems with spatial relationships. Damage tothe occipital lobe causes vision disturbances.

6. The nurse is assessing a postcraniotomyclient and finds the urine output from a catheteris 1500 ml for the 1st hour and the same for the2nd hour. The nurse should suspect:a. Cushings syndromeb. Diabetes mellitus

c. Adrenal crisisd. Diabetes insipidus

ANS: DDiabetes insipidus is an abrupt onset of extremepolyuria that commonly occurs in clients afterbrain surgery. Cushings syndrome is excessiveglucocorticoid secretion resulting in sodium andwater retention. Diabetes mellitus is ahyperglycemic state marked by polyuria,polydipsia, and polyphagia. Adrenal crisis isundersecretion of glucocorticoids resulting inprofound hypoglycemia, hypovolemia, andhypotension.

7. The nurse is providing postprocedure care fora client who underwent percutaneous lithotripsy.In this procedure, an ultrasonic probe insertedthrough a nephrostomy tube into the renal pelvisgenerates ultra-high-frequency sound waves toshatter renal calculi. The nurse should instructthe client to:


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a. limit oral fluid intake for 1 to 2 weeksb. report the presence of fine, sandlike particlesthrough the nephrostomy tube.c. Notify the physician about cloudy or foul-smelling urined. Report bright pink urine within 24 hours afterthe procedure

ANS: CThe client should report the presence of foul-smelling or cloudy urine. Unless contraindicated,the client should be instructed to drink largequantities of fluid each day to flush the kidneys.Sand-like debris is normal because of residualstone products. Hematuria is common afterlithotripsy.

8. A client with a serum glucose level of 618mg/dl is admitted to the facility. Hes awake andoriented, has hot dry skin, and has the following

vital signs: temperature of 100.6 F (38.1 C),heart rate of 116 beats/minute, and bloodpressure of 108/70 mm Hg. Based on theseassessment findings, which nursing diagnosistakes the highest priority?a. deficient fluid volume related to osmoticdiuresisb. decreased cardiac output related to elevatedheart ratec. imbalanced nutrition: Less than bodyrequirements related to insulin deficiencyd. ineffective thermoregulation related todehydration

ANS: AA serum glucose level of 618 mg/dl indicateshyperglycemia, which causes polyuria anddeficient fluid volume. In this client, tachycardiais more likely to result from deficient fluid volumethan from decreased cardiac output because hisblood pressure is normal. Although the clientsserum glucose is elevated, food isnt a prioritybecause fluids and insulin should beadministered to lower the serum glucose level.Therefore, a diagnosis of Imbalanced Nutrition:Less then body requirements isnt appropriate. A

temperature of 100.6 F isnt life threatening,eliminating ineffective thermoregulation as thetop priority.

9. Capillary glucose monitoring is beingperformed every 4 hours for a client diagnosedwith diabetic ketoacidosis. Insulin isadministered using a scale of regular insulinaccording to glucose results. At 2 p.m., the clienthas a capillary glucose level of 250 mg/dl forwhich he receives 8 U of regular insulin. Thenurse should expect the doses:a. onset to be at 2 p.m. and its peak at 3 p.m.b. onset to be at 2:15 p.m. and its peak at 3 p.m.c. onset to be at 2:30 p.m. and its peak at 4 p.m.d. onset to be at 4 p.m. and its peak at 6 p.m.

ANS: CRegular insulin, which is a short-acting insulin,has an onset of 15 to 30 minutes and a peak of2 to 4 hours. Because the nurse gave the insulinat 2 p.m., the expected onset would be from

2:15 to 2:30 p.m. and the peak from 4 p.m. to 6p.m.

10. A client with a head injury is being monitoredfor increased intracranial pressure (ICP). Hisblood pressure is 90/60 mmHG and the ICP is18 mmHg; therefore his cerebral perfusionpressure (CPP) is:a. 52 mm Hgb. 88 mm Hgc. 48 mm Hgd. 68 mm Hg

ANS: ACPP is derived by subtracting the ICP from themean arterial pressure (MAP). For adequatecerebral perfusion to take place, the minimumgoal is 70 mmHg. The MAP is derived using thefollowing formula:MAP = ((diastolic blood pressure x 2) + systolic

blood pressure) / 3MAP = ((60 x2) + 90) / 3MAP = 70 mmHgTo find the CPP, subtract the clients ICP fromthe MAP; in this case , 70 mmHg 18 mmHg =52 mmHg.

11. A 52 yr-old female tells the nurse that shehas found a painless lump in her right breastduring her monthly self-examination. Whichassessment finding would strongly suggest thatthis clients lump is cancerous?a. eversion of the right nipple and a mobile mass

b. nonmobile mass with irregular edgesc. mobile mass that is oft and easily delineatedd. nonpalpable right axillary lymph nodes

ANS: BBreast cancer tumors are fixed, hard, and poorlydelineated with irregular edges. Nipple retractionnot eversionmay be a sign of cancer. Amobile mass that is soft and easily delineated ismost often a fluid-filled benigned cyst. Axillarylymph nodes may or may not be palpable oninitial detection of a cancerous mass.

12. A Client is scheduled to have a descendingcolostomy. Hes very anxious and has manyquestions regarding the surgical procedure, careof stoma, and lifestyle changes. It would be mostappropriate for the nurse to make a referral towhich member of the health care team?a. Social workerb. registered dieticianc. occupational therapistd. enterostomal nurse therapist

ANS: DAn enterostomal nurse therapist is a registerednurse who has received advance education inan accredited program to care for clients withstomas. The enterostomal nurse therapist canassist with selection of an appropriate stomasite, teach about stoma care, and provideemotional support.

13. Ottorrhea and rhinorrhea are mostcommonly seen with which type of skull


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fracture?a. basilarb. temporalc. occipitald. parietal

ANS: AOttorrhea and rhinorrhea are classic signs ofbasilar skull fracture. Injury to the duracommonly occurs with this fracture, resulting incerebrospinal fluid (CSF) leaking through theears and nose. Any fluid suspected of beingCSF should be checked for glucose or have ahalo test done.

14. A male client should be taught abouttesticular examinations:a. when sexual activity startsb. after age 60c. after age 40

d. before age 20

ANS: DTesticular cancer commonly occurs in menbetween ages 20 and 30. A male client shouldbe taught how to perform testicular self-examination before age 20, preferably when heenters his teens.

15. Before weaning a client from a ventilator,which assessment parameter is most importantfor the nurse to review?

A. fluid intake for the last 24 hours

B. baseline arterial blood gas (ABG) levelsC. prior outcomes of weaningD. electrocardiogram (ECG) results

ANS: BBefore weaning a client from mechanicalventilation, its most important to have a baseline

ABG levels. During the weaning process, ABGlevels will be checked to assess how the client istolerating the procedure. Other assessmentparameters are less critical. Measuring fluidvolume intake and output is always importantwhen a client is being mechanically ventilated.

Prior attempts at weaning and ECG results aredocumented on the clients record, and thenurse can refer to them before the weaningprocess begins.

16. The nurse is speaking to a group of womenabout early detection of breast cancer. Theaverage age of the women in the group is 47.Following the American Cancer Society (ACS)guidelines, the nurse should recommend thatthe women:

A. perform breast self-examination annuallyB. have a mammogram annuallyC. have a hormonal receptor assay annuallyD. have a physician conduct a clinical evaluationevery 2 years

ANS: BAccording to the ACS guidelines, Women olderthan age 40 should perform breast self-examination monthly (not annually). Thehormonal receptor assay is done on a known

breast tumor to determine whether the tumor isestrogen- or progesterone-dependent.

17. When caring for a client with esophagealvarices, the nurse knows that bleeding in thisdisorder usually stems from:

A. esophageal perforationB. pulmonary hypertensionC. portal hypertensionD. peptic ulcers

ANS: CIncreased pressure within the portal veinscauses them to bulge, leading to rupture andbleeding into the lower esophagus. Bleedingassociated with esophageal varices doesntstem from esophageal perforation, pulmonaryhypertension, or peptic ulcers.

18. A 49-yer-old client was admitted for surgical

repair of a Colles fracture. An external fixatorwas placed during surgery. The surgeonexplains that this method of repair:

A. has very low complication rateB. maintains reduction and overall hand functionC. is less bothersome than a castD. is best for older people

ANS: BComplex intra-articular fractures are repairedwith external fixators because they have a betterlong-term outcome than those treated withcasting. This is especially true in a young client.

The incidence of complications, such as pin tractinfections and neuritis, is 20% to 60%. Clientsmust be taught how to do pin care and assessfor development of neurovascular complications.

19. A client is hospitalized with a diagnosis ofchronic renal failure. An arteriovenous fistulawas created in his left arm for hemodialysis.When preparing the client for discharge, thenurse should reinforce which dietary instruction?

A. Be sure to eat meat at every meal.B. Monitor your fruit intake and eat plenty ofbananas.

C. Restrict your salt intake.D. Drink plenty of fluids.

ANS: CIn a client with chronic renal failure, unrestrictedintake of sodium, protein, potassium, and f luidsmay lead to a dangerous accumulation ofelectrolytes and protein metabolic products,such as amino acids and ammonia. Therefore,the client must limit his intake of sodium, meat(high in Protein), bananas (high in potassium),and fluid because the kidneys cant secreteadequate urine.

20. The nurse is caring for a client who has justhad a modified radical mastectomy withimmediate reconstruction. Shes in her 30s andhas tow children. Although shes worried abouther future, she seems to be adjusting well to herdiagnosis. What should the nurse do to supporther coping?

A. Tell the clients spouse or partner to be


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supportive while she recovers.B. Encourage the client to proceed with the nextphase of treatment.C. Recommend that the client remain cheerfulfor the sake of her children.D. Refer the client to the American CancerSocietys Reach for Recovery program oranother support program.

ANS: DThe client isnt withdrawn or showing other signsof anxiety or depression. Therefore, the nursecan probably safely approach her about talkingwith others who have had similar experiences,either through Reach for Recovery or anotherformal support group. The nurse may educatethe clients spouse or partner to listen toconcerns, but the nurse shouldnt tell the clientsspouse what to do. The client must consult withher physician and make her own decisions

about further treatment. The client needs toexpress her sadness, frustration, and fear. Shecant be expected to be cheerful at all times.

21. A 21 year-old male has been seen in theclinic for a thickening in his right testicle. Thephysician ordered a human chorionicgonadotropin (HCG) level. The nursesexplanation to the client should include the factthat:

A. The test will evaluate prostatic function.B. The test was ordered to identify the site of apossible infection.

C. The test was ordered because clients whohave testicular cancer has elevated levels ofHCG.D. The test was ordered to evaluate thetestosterone level.

ANS: CHCG is one of the tumor markers for testicularcancer. The HCG level wont identify the site ofan infection or evaluate prostatic function ortestosterone level.

22. A client is receiving captopril (Capoten) for

heart failure. The nurse should notify thephysician that the medication therapy isineffective if an assessment reveals:

A. A skin rash.B. Peripheral edema.C. A dry cough.D. Postural hypotension.

ANS: BPeripheral edema is a sign of fluid volumeoverload and worsening heart failure. A skinrash, dry cough, and postural hypotension areadverse reactions to captopril, but the dontindicate that therapy isnt effective.

23. Which assessment finding indicatesdehydration?

A. Tenting of chest skin when pinched.B. Rapid filling of hand veins.C. A pulse that isnt easily obliterated.D. Neck vein distention

ANS: ATenting of chest skin when pinched indicatesdecreased skin elasticity due to dehydration.Hand veins fill slowly with dehydration, notrapidly. A pulse that isnt easily obliterated andneck vein distention indicate fluid overload, notdehydration.

24. The nurse is teaching a client with a historyof atherosclerosis. To decrease the risk ofatherosclerosis, the nurse should encourage theclient to:

A. Avoid focusing on his weight.B. Increase his activity level.C. Follow a regular diet.D. Continue leading a high-stress lifestyle.

ANS: BThe client should be encouraged to increase hisactivity level. Maintaining an ideal weight;

following a low-cholesterol, low-sodium diet; andavoiding stress are all important factors indecreasing the risk of atherosclerosis.

25. For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse shouldinclude which intervention in the plan of care?

A. Administer aspirin if the temperature exceeds38.8 C.B. Inspect the skin for petechiae once everyshift.C. Provide for frequent periods of rest.D. Place the client in strict isolation.

ANS: BBecause thrombocytopenia impairs bloodclotting, the nurse should assess the clientregularly for signs of bleeding, such aspetechiae, purpura, epistaxis, and bleedinggums. The nurse should avoid administeringaspirin because it can increase the risk ofbleeding. Frequent rest periods are indicated forclients with anemia, not thrombocytopenia. Strictisolation is indicated only for clients who havehighly contagious or virulent infections that arespread by air or physical contact.

26. A client is chronically short of breath and yethas normal lung ventilation, clear lungs, and anarterial oxygen saturation (SaO2) 96% or better.The client most likely has:

A. poor peripheral perfusionB. a possible Hematologic problemC. a psychosomatic disorderD. left-sided heart failure

ANS: BSaO2 is the degree to which hemoglobin issaturated with oxygen. It doesnt indicate theclients overall Hgb adequacy. Thus, anindividual with a subnormal Hgb level could havenormal SaO2 and still be short of breath. In thiscase, the nurse could assume that the client hasa Hematologic problem. Poor peripheralperfusion would cause subnormal SaO2. Thereisnt enough data to assume that the clientsproblem is psychosomatic. If the problem wereleft-sided heart failure, the client would exhibit


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pulmonary crackles.

27. For a client in addisonian crisis, it would bevery risky for a nurse to administer:

A. potassium chlorideB. normal saline solutionC. hydrocortisoneD. fludrocortisone

ANS: AAddisonian crisis results in Hyperkalemia;therefore, administering potassium chloride iscontraindicated. Because the client will behyponatremic, normal saline solution isindicated. Hydrocortisone and fludrocortisoneare both useful in replacing deficient adrenalcortex hormones.

28. The nurse is reviewing the laboratory reportof a client who underwent a bone marrow

biopsy. The finding that would most stronglysupport a diagnosis of acute leukemia is theexistence of a large number of immature:

A. lymphocytesB. thrombocytesC. reticulocytesD. leukocytes

ANS: DLeukemia is manifested by an abnormaloverpopulation of immature leukocytes in thebone marrow.

29. The nurse is performing wound care on afoot ulcer in a client with type 1 diabetesmellitus. Which technique demonstrates surgicalasepsis?

A. Putting on sterile gloves then opening acontainer of sterile saline.B. Cleaning the wound with a circular motion,moving from outer circles toward the center.C. Changing the sterile field after sterile water isspilled on it.D. Placing a sterile dressing (1.3 cm) fromthe edge of the sterile field.

ANS: CA sterile field is considered contaminated when itbecomes wet. Moisture can act as a wick,allowing microorganisms to contaminate thefield. The outside of containers, such as sterilesaline bottles, arent sterile. The containersshould be opened before sterile gloves are puton and the solution poured over the steriledressings placed in a sterile basin. Woundsshould be cleaned from the most contaminatedarea to the least contaminated areaforexample, from the center outward. The outerinch of a sterile field shouldnt be consideredsterile.

30. A client with a forceful, pounding heartbeat isdiagnosed with mitral valve prolapse. This clientshould avoid which of the following?

A. high volumes of fluid intakeB. aerobic exercise programsC. caffeine-containing productsD. foods rich in protein

ANS: CCaffeine is a stimulant, which can exacerbatepalpitations and should be avoided by a clientwith symptomatic mitral valve prolapse. High-fluid intake helps maintain adequate preload andcardiac output. Aerobic exercise helps inincrease cardiac output and decrease heart rate.Protein-rich foods arent restricted but high-calorie foods are.

31. A client with a history of hypertension isdiagnosed with primary hyperaldosteronism.This diagnosis indicates that the clientshypertension is caused by excessive hormonesecretion from which organ?

A. adrenal cortexB. pancreasC. adrenal medullaD. parathyroid

ANS: AExcessive of aldosterone in the adrenal cortex isresponsible for the clients hypertension. Thishormone acts on the renal tubule, where itpromotes reabsorption of sodium and excretionof potassium and hydrogen ions. The pancreasmainly secretes hormones involved in fuelmetabolism. The adrenal medulla secretes thecathecolaminesepinephrine andnorepinephrine. The parathyroids secreteparathyroid hormone.

32. A client has a medical history of rheumaticfever, type 1 (insulin dependent) diabetesmellitus, hypertension, pernicious anemia, andappendectomy. Shes admitted to the hospitaland undergoes mitral valve replacement surgery.

After discharge, the client is scheduled for atooth extraction. Which history finding is a majorrisk factor for infective endocarditis?

A. appendectomyB. pernicious anemiaC. diabetes mellitusD. valve replacement

ANS: DA heart valve prosthesis, such as a mitral valvereplacement, is a major risk factor for infectiveendocarditis. Other risk factors include a historyof heart disease (especially mitral valveprolapse), chronic debilitating disease, IV drugabuse, and immunosuppression. Althoughdiabetes mellitus may predispose a person tocardiovascular disease, it isnt a major risk factorfor infective endocarditis, nor is anappendectomy or pernicious anemia.

33. A 62 yr-old client diagnosed withpyelonephritis and possible septicemia has hadfive urinary tract infections over the past twoyears. Shes fatigued from lack of sleep; urinatesfrequently, even during the night; and has lostweight recently. Test reveal the following: sodiumlevel 152 mEq/L, osmolarity 340 mOsm/L,glucose level 125 mg/dl, and potassium level 3.8mEq/L. which of the following nursing diagnosesis most appropriate for this client?


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A. Deficient fluid volume related to inability toconserve waterB. Imbalanced nutrition: less than bodyrequirements related to hypermetabolic stateC. Deficient fluid volume related to osmoticdiuresis induced by hypernatremiaD. Imbalanced nutrition: less than bodyrequirements related to catabolic effects ofinsulin deficiency

ANS: AThe client has signs and symptoms of diabetesinsipidus, probably caused by the failure of herrenal tubules to respond to antidiuretic hormoneas a consequence of pyelonephritis. Thehypernatremia is secondary to her water loss.Imbalanced nutrition related to hypermetabolicstate or catabolic effect of insulin deficiency is aninappropriate nursing diagnosis for the client.

34. A 20 yr-old woman has just been diagnosedwith Crohns disease. She has lost 10 lb (4.5 kg)and has cramps and occasional diarrhea. Thenurse should include which of the followingwhen doing a nutritional assessment?

A. Let the client eat as desired during thehospitalization.B. Weight the client daily.C. Ask the client to list what she eats during atypical day.D. Place the client on I & O status and drawblood for electrolyte levels.

ANS: CWhen performing a nutritional assessment, oneof the first things the nurse should do is toassess what the client typically eats. The clientshouldnt be permitted to eat as desired.Weighing the client daily, placing her on I & Ostatus, and drawing blood to determineelectrolyte level arent part of a nutritionalassessment.

35. When instructions should be included in thedischarge teaching plan for a client afterthyroidectomy for Graves disease?

A. Keep an accurate record of intake and output.B. Use nasal desmopressin acetate DDAVP).C. Be sure to get regulate follow-up care.D. Be sure to exercise to improve cardiovascularfitness.

Regular follow-up care for the client with Gravesdisease is critical because most caseseventually result in hypothyroidism. Annualthyroid-stimulating hormone tests and theclients ability to recognize signs and symptomsof thyroid dysfunction will help detect thyroidabnormalities early. Intake and output isimportant for clients with fluid and electrolyteimbalances but not thyroid disorders. DDAVP isused to treat diabetes insipidus. While exerciseto improve cardiovascular fitness is important,for this client the importance of regular follow-upis most critical.

36. A client comes to the emergency departmentwith chest pain, dyspnea, and an irregular

heartbeat. An electrocardiogram shows a heartrate of 110 beats/minute (sinus tachycardia) withfrequent premature ventricular contractions.Shortly after admission, the client has ventriculartachycardia and becomes unresponsive. Aftersuccessful resuscitation, the client is taken tothe intensive care unit. Which nursing diagnosisis appropriate at this time?

A. Deficient knowledge related to interventionsused to treat acute illnessB. Impaired physical mobility related to completebed restC. Social isolation related to restricted visitinghours in the intensive care unitD. Anxiety related to the threat of death

ANS: DAnxiety related to the threat of death is anappropriate nursing diagnosis because theclients anxiety can adversely affect hear rate

and rhythm by stimulating the autonomicnervous system. Also, because the clientrequired resuscitation, the threat of death is areal and immediate concern. Unless anxiety isdealt with first, the clients emotional state willimpede learning. Client teaching should belimited to clear concise explanations that reduceanxiety and promote cooperation. An anxiousclient has difficulty learning, so the deficientknowledge would continue despite attempts tteaching. Impaired physical mobility and socialisolation are necessitated by the clients criticalcondition; therefore, they arent considered

problems warranting nursing diagnoses.

37. A client is admitted to the health care facilitywith active tuberculosis. The nurse shouldinclude which intervention in the plan of care?

A. Putting on a mask when entering the clientsroom.B. Instructing the client to wear a mask at alltimesC. Wearing a gown and gloves when providingdirect careD. Keeping the door to the clients room open toobserve the client

ANS: ABecause tuberculosis is transmitted by dropletnuclei from the respiratory tract, the nurseshould put on a mask when entering the clientsroom. Having the client wear a mask at all thetimes would hinder sputum expectoration andmake the mask moist from respirations. If nocontact with the clients blood or body fluids isanticipated, the nurse need not wear a gown orgloves when providing direct care. A client withtuberculosis should be in a room with laminar airflow, and the door should be closed at all times.

38. The nurse is caring for a client whounderwent a subtotal gastrectomy 24 hoursearlier. The client has a nasogastric (NG) tube.The nurse should:

A. Apply suction to the NG tube every hour.B. Clamp the NG tube if the client complains ofnausea.C. Irrigate the NG tube gently with normal saline


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solution.D. Reposition the NG tube if pulled out.

ANS: CThe nurse can gently irrigate the tube but musttake care not to reposition it. Repositioning cancause bleeding. Suction should be appliedcontinuously, not every hour. The NG tubeshouldnt be clamped postoperatively becausesecretions and gas will accumulate, stressingthe suture line.

39. Which statement about fluid replacement isaccurate for a client with hyperosmolarhyperglycemic nonketotic syndrome (HHNS)?

A. administer 2 to 3 L of IV fluid rapidlyB. administer 6 L of IV fluid over the first 24hoursC. administer a dextrose solution containingnormal saline solution

D. administer IV fluid slowly to preventcirculatory overload and collapse

ANS: ARegardless of the clients medical history, rapidfluid resuscitation is critical for maintainingcardiovascular integrity. Profound intravasculardepletion requires aggressive fluid replacement.

A typical fluid resuscitation protocol is 6 L of fluidover the first 12 hours, with more fluid to followover the next 24 hours. Various fluids can beused, depending on the degree of hypovolemia.Commonly prescribed fluids include dextran (in

case of hypovolemic shock), isotonic normalsaline solution and, when the client is stabilized,hypotonic half-normal saline solution.

40. Which of the following is an adverse reactionto glipizide (Glucotrol)?

A. headacheB. constipationC. hypotensionD. photosensitivity

ANS: DGlipizide may cause adverse skin reactions,

such as pruritus, and photosensitivity. It doesntcause headache, constipation, or hypotension.

41. The nurse is caring for four clients on a step-down intensive care unit. The client at thehighest risk for developing nosocomialpneumonia is the one who:

A. has a respiratory infectionB. is intubated and on a ventilatorC. has pleural chest tubesD. is receiving feedings through a jejunostomytube

ANS: BWhen clients are on mechanical ventilation, theartificial airway impairs the gag and coughreflexes that help keep organisms out of thelower respiratory tract. The artificial airway alsoprevents the upper respiratory system fromhumidifying and heating air to enhancemucociliary clearance. Manipulations of theartificial airway sometimes allow secretions into

the lower airways. Whit standard procedures theother choices wouldnt be at high risk.

42. The nurse is teaching a client with chronicbronchitis about breathing exercises. Which ofthe following should the nurse include in theteaching?

A. Make inhalation longer than exhalation.B. Exhale through an open mouth.C. Use diaphragmatic breathing.D. Use chest breathing.

ANS: CIn chronic bronchitis, the diaphragmatic is flatand weak. Diaphragmatic breathing helps tostrengthen the diaphragm and maximizesventilation. Exhalation should longer thaninhalation to prevent collapse of the bronchioles.The client with chronic bronchitis should exhalethrough pursed lips to prolong exhalation, keep

the bronchioles from collapsing, and prevent airtrapping. Diaphragmatic breathingnot chestbreathingincreases lung expansion.

43. A client is admitted to the hospital with anexacerbation of her chronic systemic lupuserythematosus (SLE). She gets angry when hercall bell isnt answered immediately. The mostappropriate response to her would be:

A. You seem angry. Would you like to talk aboutit?B. Calm down. You know that stress will makeyour symptoms worse.

C. Would you like to talk about the problem withthe nursing supervisor?D. I can see youre angry. Ill come back whenyouve calmed down.

ANS: AVerbalizing the observed behavior is atherapeutic communication technique in whichthe nurse acknowledges what the client isfeeling. Offering to listen to the client expressher anger can help the nurse and the clientunderstand its cause and begin to deal with it.

Although stress can exacerbate the symptoms

of SLE, telling the client to calm down doesntacknowledge her feelings. Offering to get thenursing supervisor also doesnt acknowledge theclients feelings. Ignoring the clients feelingssuggest that the nurse has no interest in whatthe client has said.

44. On a routine visit to the physician, a clientwith chronic arterial occlusive disease reportsstopping smoking after 34 years. To relivesymptoms of intermittent claudication, acondition associated with chronic arterialocclusive disease, the nurse should recommendwhich additional measure?

A. Taking daily walks.B. Engaging in anaerobic exercise.C. Reducing daily fat intake to less than 45% oftotal caloriesD. Avoiding foods that increase levels of high-density lipoproteins (HDLs)

ANS: A


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Daily walks relieve symptoms of intermittentclaudication, although the exact mechanism isunclear. Anaerobic exercise may exacerbatethese symptoms. Clients with chronic arterialocclusive disease must reduce daily fat intake to30% or less of total calories. The client shouldlimit dietary cholesterol because hyperlipidemiais associated with atherosclerosis, a knowncause of arterial occlusive disease. However,HDLs have the lowest cholesterol concentration,so this client should eat foods that raise HDLlevels.

45. A physician orders gastric decompression fora client with small bowel obstruction. The nurseshould plan for the suction to be:

A. low pressure and intermittentB. low pressure and continuousC. high pressure and continuousD. high pressure and intermittent

ANS: AGastric decompression is typically low pressureand intermittent. High pressure and continuousgastric suctioning predisposes the gastricmucosa to injury and ulceration.

46. Which nursing diagnosis is most appropriatefor an elderly client with osteoarthritis?

A. Risk for injuryB. Impaired urinary eliminationC. Ineffective breathing pattern

D. Imbalanced nutrition: less than bodyrequirements

ANS: AIn osteoarthritis, stiffness is common in large,weight bearing joints such as the hips. This jointstiffness alters functional ability and range ofmotion, placing the client at risk for falling andinjury. Therefore, client safety is in jeopardy.Osteoporosis doesnt affect urinary elimination,breathing, or nutrition.

47. Parathyroid hormone (PTH) has which

effects on the kidney?A. Stimulation of calcium reabsorption andphosphate excretionB. Stimulation of phosphate reabsorption andcalcium excretionC. Increased absorption of vit D and excretion ofvit ED. Increased absorption of vit E and excretion ofVit D

ANS: APTH stimulates the kidneys to reabsorb calciumand excrete phosphate and converts vit D to itsactive form: 1 , 25 dihydroxyvitamin D. PTHdoesnt have a role in the metabolism of Vit E.

48. A visiting nurse is performing homeassessment for a 59-yr old man recentlydischarged after hip replacement surgery. Whichhome assessment finding warrants healthpromotion teaching from the nurse?

A. A bathroom with grab bars for the tub and

toiletB. Items stored in the kitchen so that reachingup and bending down arent necessaryC. Many small, unsecured area rugsD. Sufficient stairwell lighting, with switches t thetop and bottom of the stairs

ANS: CThe presence of unsecured area rugs poses ahazard in all homes, particularly in one with aresident at high risk for falls.

49. A client with autoimmune thrombocytopeniaand a platelet count of 800/uL develops epistaxisand melena. Treatment with corticosteroids andimmunoglobulins has been unsuccessful, andthe physician recommends a splenectomy. Theclient states, I dont need surgerythis will goaway on its own. In considering her response tothe client, the nurse must depend on the ethical

principle of:A. beneficenceB. autonomyC. advocacyD. justice

ANS: BAutonomy ascribes the right of the individual tomake his own decisions. In this case, the clientis capable of making his own decision and thenurse should support his autonomy. Beneficenceand justice arent the principles that directlyrelate to the situation. Advocacy is the nurses

role in supporting the principle of autonomy.

50. Which of the following is t he most criticalintervention needed for a client with myxedemacoma?

A. Administering and oral dose of levothyroxine(Synthroid)B. Warming the client with a warming blanketC. Measuring and recording accurate intake andoutputD. Maintaining a patent airway

ANS: D

Because respirations are depressed inmyxedema coma, maintaining a patent airway isthe most critical nursing intervention. Ventilatorysupport is usually needed. Thyroid replacementwill be administered IV. Although myxedemacoma is associated with severe hypothermia, awarming blanket shouldnt be used because itmay cause vasodilation and shock. Gradualwarming blankets would be appropriate. Intakeand output are very important but arent criticalinterventions at this time.

MEDICAL-SURGICAL PART2

51. Because diet and exercise have failed tocontrol a 63 yr-old clients blood glucose level,the client is prescribed glipizide (Glucotrol). Afteroral administration, the onset of action is:A. 15to 30 minutesB. 30 to 60 minutesC. 1 to 1 hoursD. 2 to 3 hours


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ANS: AGlipizide begins to act in 15 to 30 minutes. Theother options are incorrect.

52. A client with pneumonia is receivingsupplemental oxygen, 2 L/min via nasal cannula.The clients history includes chronic obstructivepulmonary disease (COPD) and coronary arterydisease. Because of these findings, the nurseclosely monitors the oxygen flow and the clientsrespiratory status. Which complication may ariseif the client receives a high oxygenconcentration?

A. ApneaB. Anginal painC. Respiratory alkalosisD. Metabolic acidosis

ANS: A

Hypoxia is the main breathing stimulus for aclient with COPD. Excessive oxygenadministration may lead to apnea by removingthat stimulus. Anginal pain results from areduced myocardial oxygen supply. A client withCOPD may have anginal pain from generalizedvasoconstriction secondary to hypoxia; however,administering oxygen at any concentrationdilates blood vessels, easing anginal pain.Respiratory alkalosis results from alveolarhyperventilation, not excessive oxygenadministration. In a client with COPD, highoxygen concentrations decrease the ventilatory

drive, leading to respiratory acidosis, notalkalosis. High oxygen concentrations dontcause metabolic acidosis.

53. A client with type 1 diabetes mellitus hasbeen on a regimen of multiple daily injectiontherapy. Hes being converted to continuoussubcutaneous insulin therapy. While teachingthe client bout continuous subcutaneous insulintherapy, the nurse would be accurate in tellinghim the regimen includes the use of:

A. intermediate and long-acting insulinsB. short and long-acting insulins

C. short-acting onlyD. short and intermediate-acting insulins

ANS: CContinuous subcutaneous insulin regimen usesa basal rate and boluses of short-acting insulin.Multiple daily injection therapy uses acombination of short-acting and intermediate orlong-acting insulins.54. a client who recently had a cerebrovascularaccident requires a cane to ambulate. Whenteaching about cane use, the rationale forholding a cane on the uninvolved side is to:

A. prevent leaningB. distribute weight away from the involved sideC. maintain stride lengthD. prevent edema

ANS: BHolding a cane on the uninvolved sidedistributes weight away from the involved side.Holding the cane close to the body prevents

leaning. Use of a cane wont maintain stridelength or prevent edema.

55. A client with a history of an anterior wallmyocardial infarction is being transferred fromthe coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving report to the CSUnurse, the CCU nurse says, His pulmonaryartery wedge pressures have been in the highnormal range. The CSU nurse should beespecially observant for:

A. hypertensionB. high urine outputC. dry mucous membranesD. pulmonary crackles

ANS: DHigh pulmonary artery wedge pressures arediagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can

develop causing pulmonary crackles. In left-sided heart failure, hypotension may result andurine output will decline. Dry mucousmembranes arent directly associated withelevated pulmonary artery wedge pressures.56. The nurse is caring for a client with afractures hip. The client is combative, confused,and trying to get out of bed. The nurse should:

A. leave the client and get helpB. obtain a physicians order to restrain the clientC. read the facilitys policy on restraintsD. order soft restraints from the storeroom

ANS: BIts mandatory in most settings to have aphysicians order before restraining a client. Aclient should never be left alone while the nursesummons assistance. All staff members requireannual instruction on the use of restraints, andthe nurse should be familiar with the facilityspolicy.

57. For the first 72 hours after thyroidectomysurgery, the nurse would assess the client forChvosteks sign and Trousseaus sign becausethey indicate which of the following?A.

hypocalcemiaB. hypercalcemiaC. hypokalemiaD. Hyperkalemia

ANS: AThe client who has undergone a thyroidectomyis t risk for developing hypocalcemia frominadvertent removal or damage to theparathyroid gland. The client with hypocalcemiawill exhibit a positive Chvosteks sign (facialmuscle contraction when the facial nerve in frontof the ear is tapped) and a positive Trousseaussign (carpal spasm when a blood pressure cuffis inflated for few minutes). These signs arentpresent with hypercalcemia, hypokalemia, orHyperkalemia.

58. In a client with enteritis and frequentdiarrhea, the nurse should anticipate an acid-base imbalance of:

A. respiratory acidosis


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B. respiratory alkalosisC. metabolic acidosisD. metabolic alkalosis

ANS: CDiarrhea causes a bicarbonate deficit. With lossof the relative alkalinity of the lower GI tract, therelative acidity of the upper GI tractpredominates leading to metabolic acidosis.Diarrhea doesnt lead to respiratory acid-baseimbalances, such as respiratory acidosis andrespiratory alkalosis. Loss of acid, which occurswith severe vomiting, may lead to metabolicalkalosis.

59. When caring for a client with the nursingdiagnosis Impaired swallowing related toneuromuscular impairment, the nurse should:

A. position the client in a supine positionB. elevate the head of the bed 90 degrees

during mealsC. encourage the client to remove denturesD. encourage thin liquids for dietary intake

ANS: BThe head of the bed must be elevated while theclient is eating. The client should be placed in arecumbent positionnot a supine positionwhen lying down to reduce the risk of aspiration.Encourage the client to wear properly fitteddentures to enhance his chewing ability.Thickened liquids, not thin liquids, decreaseaspiration risk.

60. A nurse is caring for a client who has atracheostomy and temperature of 39 C. whichintervention will most likely lower the clientsarterial blood oxygen saturation?

A. Endotracheal suctioningB. Encouragement of coughingC. Use of cooling blanketD. Incentive spirometry

ANS: AEndotracheal suctioning secretions as well asgases from the airway and lowers the arterial

oxygen saturation (SaO2) level. Coughing andincentive spirometry improve oxygenation andshould raise or maintain oxygen saturation.Because of superficial vasoconstriction, using acooling blanket can lower peripheral oxygensaturation readings, but SaO2 levels wouldnt beaffected.

61. A client with a solar burn of the chest, back,face, and arms is seen in urgent care. Thenurses primary concern should be:A. fluidresuscitationB. infectionC. body imageD. pain management

ANS: DWith a superficial partial thickness burn such asa solar burn (sunburn), the nurses main concernis pain management. Fluid resuscitation andinfection become concerns if the burn extends tothe dermal and subcutaneous skin layers. Body

image disturbance is a concern that has a lowerpriority than pain management.

62. Which statement is true about crackles?A. Theyre grating sounds.B. Theyre high-pitched, musical squeaks.C. Theyre low-pitched noises that sound likesnoring.D. They may be fine, medium, or course.

ANS: DCrackles result from air moving through airwaysthat contain fluid. Heard during inspiration andexpiration, crackles are discrete sounds thatvary in pitch and intensity. Theyre classified asfine, medium, or coarse. Pleural friction rubshave a distinctive grating sound. As the nameindicates, these breath sounds result wheninflamed pleurae rub together. Continuous, high-pitched, musical squeaks, called wheezes, result

when air moves rapidly through airwaysnarrowed by asthma or infection or when anairway is partially obstructed by a tumor orforeign body. Wheezes, like gurgles, occur onexpiration and sometimes on inspiration. Loud,coarse, low-pitched sounds resembling snoringare called gurgles. These sounds develop whenthick secretions partially obstruct airflow throughthe large upper airways.

63. A woman whose husband was recentlydiagnosed with active pulmonary tuberculosis(TB) is a tuberculin skin test converter.

Management of her care would include:A. scheduling her for annual tuberculin skintestingB. placing her in quarantine until sputumcultures are negativeC. gathering a list of persons with whom she hashad recent contactD. advising her to begin prophylactic therapywith isoniazid (INH)

Individuals who are tuberculin skin testconverters should begin a 6-month regimen ofan antitubercular drug such as INH, and they

should never have another skin test. After anindividual has a positive tuberculin skin test,subsequent skin tests will cause severe skinreactions but wont provide new informationabout the clients TB status. The client doesnthave active TB, so cant transmit, or spread, thebacteria. Therefore, she shouldnt bequarantined or asked for information aboutrecent contacts.

64. The nurse is caring for a client who ahs hadan above the knee amputation. The clientrefuses to look at the stump. When the nurseattempts to speak with the client about hissurgery, he tells the nurse that he doesnt wishto discuss it. The client also refuses to have hisfamily visit. The nursing diagnosis that bestdescribes the clients problem is:

A. HopelessnessB. PowerlessnessC. Disturbed body imageD. Fear


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ANS: CDisturbed body image is a negative perceptionof the self that makes healthful functioning moredifficult. The defining characteristics for thisnursing diagnosis include undergoing a changein body structure or function, hiding oroverexposing a body part, not looking at a bodypart, and responding verbally or nonverbally tothe actual or perceived change in structure orfunction. This client may have any of the otherdiagnoses, but the signs and symptomsdescribed in he case most closely match thedefining characteristics for disturbed bodyimage.

65. A client with three children who is still I thechild bearing years is admitted for surgical repairof a prolapsed bladder. The nurse would findthat the client understood the surgeons

preoperative teaching when the client states:A. If I should become pregnant again, the childwould be delivered by cesarean delivery.B. If I have another child, the procedure mayneed to be repeated.C. This surgery may render me incapable ofconceiving another child.D. This procedure is accomplished in twoseparate surgeries.

ANS: BBecause the pregnant uterus exerts a lot ofpressure on the urinary bladder, the bladder

repair may need to be repeated. These clientsdont necessarily have to have a cesareandelivery if they become pregnant, and thisprocedure doesnt render them sterile. Thisprocedure is completed in one surgery.

66. A client experiences problems in bodytemperature regulation associated with a skinimpairment. Which gland is most likely involved?

A. EccrineB. SebaceousC. ApocrineD. Endocrine

ANS: AEccrine glands are associated with bodytemperature regulation. Sebaceous glandslubricate the skin and hairs, and apocrine glandsare involved in bacteria decomposition.Endocrine glands secrete hormones responsiblefor the regulation of body processes, such asmetabolism and glucose regulation.

67. A school cafeteria worker comes to thephysicians office complaining of severe scalpitching. On inspection, the nurse finds nail markson the scalp and small light-colored roundspecks attached to the hair shafts close to thescalp. These findings suggest that the clientsuffers from:

A. scabiesB. head liceC. tinea capitisD. impetigo

ANS: BThe light-colored spots attached to the hairshafts are nits, which are the eggs of head lice.They cant be brushed off the hair shaft likedandruff. Scabies is a contagious dermatitiscaused by the itch mite, Sacoptes scabiei, whichlives just beneath the skin. Tinea capitis, orringworm, causes patchy hair loss and circularlesions with healing centers. Impetigo is aninfection caused by Staphylococcus orSterptococcus, manifested by vesicles orpustules that form a thick, honey-colored crust.

68. Following a small-bowel resection, a clientdevelops fever and anemia. The surfacesurrounding the surgical wound is warm to touchand necrotizing fasciitis is suspected. Anothermanifestation that would most suggestnecrotizing fasciitis is:

A. erythema

B. leukocytosisC. pressure-like painD. swelling

ANS: CSevere pressure-like pain out of proportion tovisible signs distinguishes necrotizing fasciitisfrom cellulites. Erythema, leukocytosis, andswelling are present in both cellulites andnecrotizing fasciitis.

69. A 28 yr-old nurse has complaints of itchingand a rash of both hands. Contact dermatitis is

initially suspected. The diagnosis is confirmed ifthe rash appears:

A. erythematous with raised papulesB. dry and scaly with flaking skinC. inflamed with weeping and crusting lesionsD. excoriated with multiple fissures

ANS: AContact dermatitis is caused by exposure to aphysical or chemical allergen, such as cleaningproducts, skin care products, and latex gloves.Initial symptoms of itching, erythema, and raisedpapules occur at the site of the exposure and

can begin within 1 hour of exposure. Allergicreactions tend to be red and not scaly or flaky.Weeping, crusting lesions are also uncommonunless the reaction is quite severe or has beenpresent for a long time. Excoriation is morecommon in skin disorders associated with amoist environment.

70. When assessing a client with partialthickness burns over 60% of the body, which ofthe following should the nurse reportimmediately?

A. Complaints of intense thirstB. Moderate to severe painC. Urine output of 70 ml the 1st hourD. Hoarseness of the voice

ANS: DHoarseness indicate injury to the respiratorysystem and could indicate the need forimmediate intubation. Thirst following burns isexpected because of the massive fluid shifts and


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resultant loss leading to dehydration. Pain,either severe or moderate, is expected with aburn injury. The clients output is adequate.

71. A client is admitted to the hospital following aburn injury to the left hand and arm. The clientsburn is described as white and leathery with noblisters. Which degree of severity is this burn?

A. first-degree burnB. second-degree burnC. third-degree burnD. fourth-degree burn

ANS: CThird-degree burn may appear white, red, orblack and are dry and leathery with no blisters.There may be little pain because nerve endingshave been destroyed. First-degree burns aresuperficial and involve the epidermis only. Thereis local pain and redness but no blistering.

Second-degree burn appear red and moist withblister formation and are painful. Fourth-degreeburns involve underlying muscle and bonetissue.

72. The nurse is caring for client with a newdonor site that was harvested to treat a newburn. The nurse position the client to:

A. allow ventilation of the siteB. make the site dependentC. avoid pressure on the siteD. keep the site fully covered

ANS: CA universal concern I the care of donor sites forburn care is to keep the site away from sourcesof pressure. Ventilation of the site and keepingthe site fully covered are practices in someinstitutions but arent hallmarks of donor sitecare. Placing the site in a position ofdependence isnt a justified aspect of donor sitecare.

73. a 45-yr-old auto mechanic comes to thephysicians office because an exacerbation ofhis psoriasis is making it difficult to work. He tells

the nurse that his finger joints are stiff and sorein the morning. The nurse should respond by:A. Inquiring further about this problem becausepsoriatic arthritis can accompany psoriasisvulgarisB. Suggesting he take aspirin for relief becauseits probably early rheumatoid arthritisC. Validating his complaint but assuming its anadverse effect of his vocationD. Asking him if he has been diagnosed ortreated for carpal tunnel syndrome

ANS: AAnyone with psoriasis vulgaris who reports jointpain should be evaluated for psoriaic arthritis.

Approximately 15% to 20% of individuals withpsoriasis will also develop psoriatic arthritis,which can be painful and cause deformity. Itwould be incorrect to assume that his pain iscaused by early rheumatoid arthritis or hisvocation without asking more questions orperforming diagnostic studies. Carpal tunnel

syndrome causes sensory and motor changes inthe fingers rather than localized pain in the

joints.

74. The nurse is providing home careinstructions to a client who has recently had askin graft. Which instruction is most important forthe client to remember?

A. Use cosmetic camouflage techniques.B. Protect the graft from direct sunlight.C. Continue physical therapy.D. Apply lubricating lotion to the graft site.

ANS: BTo avoid burning and sloughing, the client mustprotect the graft from sunlight. The other threeinterventions are all helpful to the client and hisrecovery but are less important.

75. a 28 yr-old female nurse is seen in the

employee health department for mild itching andrash of both hands. Which of the following couldbe causing this reaction?

A. possible medication allergiesB. current life stressors she may beexperiencingC. chemicals she may be using and use of latexglovesD. recent changes made in laundry detergent orbath soap.

ANS: CBecause the itching and rash are localized, an

environmental cause in the workplace should besuspected. With the advent of universalprecautions, many nurses are experiencingallergies to latex gloves. Allergies tomedications, laundry detergents, or bath soapsor a dermatologic reaction to stress usually elicita more generalized or widespread rash.

76. The nurse assesses a client with urticaria.The nurse understands that urticaria is anothername for:

A. hivesB. a toxin

C. a tubercleD. a virus

ANS: AHives and urticaria are two names for the sameskin lesion. Toxin is a poison. A tubercle is a tinyround nodule produced by the tuberculosisbacillus. A virus is an infectious parasite.

77. A client with psoriasis visits the dermatologyclinic. When inspecting the affected areas, thenurse expects to see which type of secondarylesion?

A. scaleB. crustC. ulcerD. scar

ANS: AA scale is the characteristic secondary lesionoccurring in psoriasis. Although crusts, ulcers,and scars also are secondary lesions in skin


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disorders, they dont accompany psoriasis.

78. The nurse is caring for a bedridden, elderlyadult. To prevent pressure ulcers, whichintervention should the nurse include in the planof care?

A. Turn and reposition the client a minimum ofevery 8 hours.B. Vigorously massage lotion into bonyprominences.C. Post a turning schedule at the clientsbedside.D. Slide the client, rather than lifting whenturning.

ANS: CA turning schedule with a signing sheet will helpensure that the client gets turned and thus, helpprevent pressure ulcers. Turning should occurevery 1-2 hoursnot every 8 hoursfor clients

who are in bed for prolonged periods. The nurseshould apply lotion to keep the skin moist butshould avoid vigorous massage, which coulddamage capillaries. When moving the client, thenurse should lift rather than slide the client tovoid shearing.

79. Following a full-thickeness (3rd degree) burnof his left arm, a client is treated with artificialskin. The client understands postoperative careof the artificial skin when he states that duringthe first 7 days after the procedure, hell restrict:

A. range of motion

B. protein intakeC. going outdoorsD. fluid ingestion

ANS: ATo prevent disruption of the artificial skinsadherence to the wound bed, the client shouldrestrict range of motion of the involved limb.Protein intake and fluid intake are important forhealing and regeneration and shouldnt berestricted. Going outdoors is acceptable as longas the left arm is protected from direct sunlight.

80. A client received burns to his entire back andleft arm. Using the Rule of Nines, the nurse cancalculate that he has sustained burns on whatpercentage of his body?

A. 9%B. 18%C. 27%D. 36%

ANS: CAccording to the Rule of Nines, the posterior andanterior trunk, and legs each make up 18% ofthe total body surface. The head, neck, andarms each make up 9% of total body durface,and the perineum makes up 1%. In this case,the client received burns to his back (18%) andone arm (9%), totaling 27%.

81. The nurse is providing care for a client whohas a sacral pressure ulcer with wet-to-drydressing. Which guideline is appropriate for awet-to-dry dressing?

A. The wound should remain moist form thedressing.B. The wet-to-dry dressing should be tightlypacked into the wound.C. The dressing should be allowed to dry outbefore removal.D. A plastic sheet-type dressing should cover thewet dressing.

ANS: AA wet-to-dry saline dressing should always keepthe wound moist. Tight packing or dry packingcan cause tissue damage and pain. A dry gauzenot a plastic-sheet-type dressingshouldcover the wet dressing.

82. While in skilled nursing facility, a clientcontracted scabies, which is diagnosed the dayafter discharge. The client is living at herdaughters home with six other persons. During

her visit to the clinic, she asks a staff nurse,What should my family do? the most accurateresponse from the nurse is:

A. All family members will need to be treated.B. If someone develops symptoms, tell him tosee a physician right away.C. Just be careful not to share linens andtowels with family members.D. After youre treated, family members wontbe at risk for contracting scabies.

ANS: AWhen someone in a group of persons sharing a

home contracts scabies, each individual in thesame home needs prompt treatment whetherhes symptomatic or not. Towels and linensshould be washed in hot water. Scabies can betransmitted from one person to another beforesymptoms develop

83. In an industrial accident, client who weighs155 lb (70.3 kg) sustained full-thickness burnsover 40% of his body. Hes in the burn unitreceiving fluid resuscitation. Which observationshows that the fluid resuscitation is benefitingthe client?

A. A urine output consistently above 100ml/hour.B. A weight gain of 4 lb (1.8 kg) in 24 hours.C. Body temperature readings all within normallimitsD. An electrocardiogram (ECG) showing noarrhythmias.

ANS: AIn a client with burns, the goal of fluidresuscitation is to maintain a mean arterial bloodpressure that provides adequate perfusion ofvital structures. If the kidneys are adequatelyperfused, they will produce an acceptable urineoutput of at least 0.5 ml/kg/hour. Thus, theexpected urine output of a 155-lb client is 35ml/hour, and a urine output consistently above100 ml/hour is more than adequate. Weight gainfrom fluid resuscitation isnt a goal. In fact, a 4 lbweight gain in 24 hours suggests third spacing.Body temperature readings and ECGinterpretations may demonstrate secondary


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benefits of fluid resuscitation but arent primaryindicators.

84. The nurse is reviewing the laboratory resultsof a client with rheumatoid arthritis. Which of thefollowing laboratory results should the nurseexpect to find?

A. Increased platelet countB. Elevated erythrocyte sedimentation rate(ESR)C. Electrolyte imbalanceD. Altered blood urea nitrogen (BUN) andcreatinine levels

ANS: BThe ESR test is performed to detectinflammatory processes in the body. Its anonspecific test, so the health care professionalmust view results in conjunction with physicalsigns and symptoms. Platelet count,

electrolytes, BUN, and creatinine levels arentusually affected by the inflammatory process.

85. Which nursing diagnosis takes the highestpriority for a client with Parkinsons crisis?

A. Imbalanced nutrition: less than bodyrequirementsB. Ineffective airway clearanceC. Impaired urinary eliminationD. Risk for injury

ANS: BIn Parkinsons crisis, dopamine-related

symptoms are severely exacerbated, virtuallyimmobilizing the client. A client who is confinedto bed during a crisis is at risk for aspiration andpneumonia. Also, excessive drooling increasesthe risk of airway obstruction. Because of theseconcerns, ineffective airway clearance is thepriority diagnosis for this client. Althoughimbalanced nutrition:less than bodyrequirements, impaired urinary elimination andrisk for injury also are appropriate diagnoses forthis client, they arent immediately life-threatening and thus are less urgent.

86. A client with a spinal cord injury andsubsequent urine retention receives intermittentcatheterization every 4 hours. The averagecatheterized urine volume has been 550 ml. Thenurse should plan to:

A. Increase the frequency of thecatheterizations.B. Insert an indwelling urinary catheterC. Place the client on fluid restrictionsD. Use a condom catheter instead of an invasiveone.

ANS: AAs a rule of practice, if intermittentcatheterization for urine retention typically yields500 ml or more, the frequency of catheterizationshould be increased. Indwelling catheterizationis less preferred because of the risk of urinarytract infection and the loss of bladder tone. Fluidrestrictions arent indicated for this case; theproblem isnt overhydration, rather its urineretention. A condom catheter doesnt help empty

the bladder of a client with urine retention.

87.The nurse is caring for a client who is toundergo a lumbar puncture to assess for thepresence of blood in the cerebrospinal fluid(CSF) and to measure CSF pressure. Whichresult would indicate n abnormality?

A. The presence of glucose in the CSF.B. A pressure of 70 to 200 mm H2OC. The presence of red blood cells (RBCs) in thefirst specimen tubeD. A pressure of 00 to 250 mmH2O

ANS: DThe normal pressure is 70 to 200 mm H2O areconsidered abnormal. The presence of glucoseis an expected finding in CSF, and RBCstypically occur in the first specimen tube fromthe trauma caused by the procedure.

88. The nurse is administering eyedrops to aclient with glaucoma. To achieve maximumabsorption, the nurse should instill the eyedropinto the:

A. conjunctival sacB. pupilC. scleraD. vitreous humor

ANS: AThe nurse should instill the eyedrop into theconjunctival sac where absorption can best takeplace. The pupil permits light to enter the eye.

The sclera maintains the eyes shape and size.The vitreous humor maintains the retinasplacement and the shape of the eye.

89. A 52 yr-old married man with two adolescentchildren is beginning rehabilitation following acerebrovascular accident. As the nurse isplanning the clients care, the nurse shouldrecognize that his condition will affect:

A. only himselfB. only his wife and childrenC. him and his entire familyD. no one, if he has complete recovery

ANS: CAccording to family theory, any change ina family member, such as illness, produces rolechanges in all family members and affects theentire family, even if the client eventuallyrecovers completely.

90. Which action should take the highest prioritywhen caring for a client with hemiparesis causedby a cerebrovascular accident (CVA)?

A. Perform passive range-of-motion (ROM)exercises.B. Place the client on the affected side.C. Use hand rolls or pillows for support.D. Apply antiembolism stockings

ANS: BTo help prevent airway obstruction and reducethe risk of aspiration, the nurse should position aclient with hemiparesis on the affected side.

Although performing ROM exercises, providingpillows for support, and applying antiembolism


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stockings can be appropriate for a client withCVA, the first concern is to maintain a patentairway.

91. The nurse is formulating a teaching plan fora client who has just experienced a transientischemic attack (TIA). Which fact should thenurse include in the teaching plan?

A. TIA symptoms may last 24 to 48 hours.B. Most clients have residual effects after havinga TIA.C. TIA may be a warning that the client mayhave cerebrovascular accident (CVA)D. The most common symptom of TIA is theinability to speak.

ANS: CTIA may be a warning that the client willexperience a CVA, or stroke, in the near future.TIA aymptoms last no longer than 24 hours and

clients usually have complete recovery after TIA.The most common symptom of TIA is sudden,painless loss of vision lasting up to 24 hours.

92. The nurse has just completed teaching aboutpostoperative activity to a client who is going tohave a cataract surgery. The nurse knows theteaching has been effective if the client:

A. coughs and deep breathes postoperativelyB. ties his own shoesC. asks his wife to pick up his shirt from the floorafter he drops it.D. States that he doesnt need to wear an

eyepatch or guard to bed

ANS: CBending to pick up something from the floorwould increase intraocular pressure, as wouldbending to tie his shoes. The client needs towear eye protection to bed to prevent accidentalinjury during sleep.

93. The least serious form of brain trauma,characterized by a brief loss of consciousnessand period of confusion, is called:

A. contusion

B. concussionC. coupD. contrecoup

ANS: BConcussions are considered minor with nostructural signs of injury. A contusion is bruisingof the brain tissue with small hemorrhages in thetissue. Coup and contrecoup are type of injuriesin which the damaged area on the brain formsdirectly below that site of impact (coup) or at thesite opposite the injury (contrecoup) due tomovement of the brain within the skull.

94. When the nurse performs a neurologicassessment on Anne Jones, her pupils aredilated and dont respond to light.

A. glaucomaB. damage to the third cranial nerveC. damage to the lumbar spineD. Bells palsy

ANS: BThe third cranial nerve (oculomotor) isresponsible for pupil constriction. When there isdamage to the nerve, the pupils remain dilatedand dont respond to light. Glaucoma, lumbarspine injury, and Bells palsy wont affect pupilconstriction.

95. A 70 yr-old client with a diagnosis of left-sided cerebrovascular accident is admitted tothe facility. To prevent the development of diffuseosteoporosis, which of the following objectives ismost appropriate?

A. Maintaining protein levels.B. Maintaining vitamin levels.C. Promoting weight-bearing exercisesD. Promoting range-of-motion (ROM) exercises

ANS: CWhen the mechanical stressors of weightbearing are absent, diffuse osteoporosis can

occur. Therefore, if the client does weight-bearing exercises, disuse complications can beprevented. Maintaining protein and vitaminslevels is important, but neither will preventosteoporosis. ROM exercises will help preventmuscle atrophy and contractures.

96. A client is admitted with a diagnosis ofmeningitis caused by Neisseria meningitides.The nurse should institute which type of isolationprecautions?

A. Contact precautionsB. Droplet precautions

C. Airborne precautionsD. Standard precautions

ANS: BThis client requires droplet precautions becausethe organism can be transmitted throughairborne droplets when the client coughs,sneezes, or doesnt cover his mouth. Airborneprecautions would be instituted for a clientinfected with tuberculosis. Standard precautionswould be instituted for a client when contact withbody substances is likely. Contact precautionswould be instituted for a client infected with an

organism that is transmitted through skin-to-skincontact.

97. A young man was running along an oceanpier, tripped on an elevated area of the decking,and struck his head on the pier railing. Accordingto his friends, He was unconscious briefly andthen became alert and behaved as thoughnothing had happened. Shortly afterward, hebegan complaining of a headache and asked tobe taken to the emergency department. If theclients intracranial pressure (ICP) is increasing,the nurse would expect to observe which of thefollowing signs first?

A. pupillary asymmetryB. irregular breathing patternC. involuntary posturingD. declining level of consciousness

ANS: DWith a brain injury such as an epiduralhematoma (a diagnosis that is most likely based


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on this clients symptoms), the initial sign ofincreasing ICP is a change in the level ofconsciousness. As neurologic deteriorationprogresses, manifestations involving pupillarysymmetry, breathing patterns, and posturing willoccur.

98. Emergency medical technicians transport a28 yr-old iron worker to the emergencydepartment. They tell the nurse, He fell from atwo-story building. He has a large contusion onhis left chest and a hematoma in the left parietalarea. He has compound fracture of his left femurand hes comatose. We intubated him and hesmaintaining an arterial oxygen saturation of 92%by pulse oximeter with a manual-resuscitationbag. Which intervention by the nurse has thehighest priority?

A. Assessing the left legB. Assessing the pupils

C. Placing the client in Trendelenburgs positionD. Assessing the level of consciousness

ANS: AIn the scenario, airway and breathing areestablished so the nurses next priority should becirculation. With a compound fracture of thefemur, there is a high risk of profuse bleeding;therefore, the nurse should assess the site.Neurologic assessment is a secondary concernto airway, breathing and circulation. The nursedoesnt have enough data to warrant putting theclient in Trendelenburgs position.

99. Alzheimers disease is the secondarydiagnosis of a client admitted with myocardialinfarction. Which nursing intervention shouldappear on this clients plan of care?

A. Perform activities of daily living for the clientto decease frustration.B. Provide a stimulating environment.C. Establish and maintain a routine.D. Try to reason with the client as much aspossible.

ANS: C

Establishing and maintaining a routine isessential to decreasing extraneous stimuli. Theclient should participate in daily care as much aspossible. Attempting to reason with such clientsisnt successful, because they cant participate inabstract thinking.

100. For a client with a head injury whose neckhas been stabilized, the preferred bed positionis:

A. TrendelenburgsB. 30-degree head elevationC. flatD. side-lying

ANS: BFor clients with increased intracranial pressure(ICP), the head of the bed is elevated topromote venous outflow. Trendelenburgsposition is contraindicated because it can raiseICP. Flat or neutral positioning is indicated whenelevating the head of the bed would increase the

risk of neck injury or airway obstruction. Side-lying isnt specifically a therapeutic treatment forincreased ICP.

101. In a comatose client, hearing is the lastsense to be lost. Therefore, the nurse shouldalways:

A. talk loudly in case the client can hearB. speak softly before touching the clientC. tell others in the room not to talk to the clientD. tell family members that the client probablycant hear

ANS: BMany clients have reported being able to hearwhen being in a comatose state. Therefore, thenurse should converse as if the client was alertand oriented. Talking loudly is only appropriate ifthe client is hard of hearing, and family membersshould be encouraged to talk with the client

unless contraindicated.

102. When a client experiences loss of vibratorysense on examination, this indicates:

A. injury to the cranial nervesB. injury to the peripheral nervesC. intact cranial nervesD. intact peripheral nerves

ANS: BAppropriate perception of vibration indicatesintact dorsal column tracts and peripheralnerves. If theres a loss of vibratory sense, an

injury to the peripheral nerves is probable.

Exam Questions - Med Surg

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